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SUPERVISOR

dr. Sabar P. Siregar, Sp.KJ

MORNING REPORTFriday, May 9th 2014


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Patient IdentityAutoanamnesis Name : Sex : Age : years old Address : Occupation : Marital State :

Alloanamnesis Name : Sex : Relation :


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Reason patient was brought to

emergency room

Patient refuse to take his medicine andshowing weird behavior


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Stressor

Meeting his wife and childrenwho didnt live in the same house


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Past HistoryPatient has history of hospitalization at 2003, 2009,2 times at 2010, 2013, and March 2014.

He usually brought to hospital because of goingmad, refusing to take his medicine, wanderingaround, and disturbing his neighbours.He started showing symptoms around 2003because he was fired from his job in Jakarta. Andstarted living separately from his wife and children.His smoking habit became more frequent whenhes about to relapse.


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Day of Admission

9th May 2014

Patient brought with thecomplaints of:

Didnt take his medicine Refused going to hospital for

routine control Giving his wares to other people

without any reason

Brought to hospitalby his mother

He worked as a merchantPoor utilization of leisure time

He could nt socialize with friendsThe patient didnt take any medicine

for 4 days


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Generalmedical history

Head injury (-) Hypertension (-) Convulsion (-) Asthma (-) Allergy (-)

Drugs and alcoholabuse history andsmoking history

Drugs consumption (-) Alcohol consumption (-) Cigarette Smoking (+) - frequencyincreased when symptoms worsened


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ADULTHOODEducational History He finished junior highschool

Occupational historyHe started to work inJakarta when he was 15 yrold. His mother didnt know anything about hisoccupation.

Marital StatusMarried, but not living inthe same house

Criminal HistoryNo

Social Activity

Before he was sick, he wasa friendly guy and hadmany friends

Current SituationHe lives with his parents,

he has no friends. And heworks as a merchant


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FAMILY HISTORY

Patient is the 2nd child of 4 siblings

Psychiatry history in the family his youngersister also has same symptom


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GENOGRAM

Pria Wanita Pasien Meninggal


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PSYCHOSEXUAL HISTORY

Patient realizes that he is a male, and interested infemale. His attitude is appropriate as a male.


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Socio-economic history Economic scale : low

Validity

Alloanamnesis: valid Autoanamnesis: valid


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Progression of Disorder

Symptom

Role Function

2003 2013 20142009 2010 2010


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Appearance A male, appropriate to his age, completely clothed,

nicely groomed

State of Consciousness Clear

Speech Quantity : Increased Quality : Decreased

Mental State May 9 th 2014


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BEHAVIOUR

Hypoactive Hyperactive Echopraxia

Catatonia Active negativism Cataplexy Streotypy Mannerism Automatism Bizzare

Command automatism Mutism Acathysia Tic Somnabulism Psychomotor agitation Compulsive Ataxia Mimicry Aggresive Impulsive Abulia


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ATTITUDE

Non-cooperative Indiferrent Apathy Tension Dependent Passive

Infantile Distrust Labile

Rigid Passive negativism Stereotypy Catalepsy

Cerea flexibility Excited Stable


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Emotion

Mood

Dysphoric Euthymic Elevated Euphoria

Expansive Irritable Agitation Cant be assesed

Affect

Appropriate Inappropriate Broad Restrictive Blunted Flat Stable Labile


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Disturbance of Perception

Hallucination

Auditory (-) Visual (-) Olfactory (-) Gustatory (-) Tactile (-) Somatic (-)

Illusion

Auditory (-) Visual (-) Olfactory (-) Gustatory (+) Tactile (-) Somatic (-)

Depersonalization (-) Derealization (-)


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Thought Progression

Quantity

Logorrhea Blocking Remming Mutism

Talkative

Quality

Irrelevant answer

Incoherence Flight of idea Poverty of speech Confabulation Loosening of association Neologisme

Circumtansiality Tangential Verbigration Perseveration Sound association Word salad

Echolalia


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Content of Thought

Idea of Reference Idea of Guilt

Preoccupation

Obsession

Phobia

Fantasy

Delusion of Persecution

Delusion of Reference Delusion of Envious Delusion of Hypochondriac

Delusion of Magic-mystic

Delusion of Grandiose Delusion of Control Delusion of Religion Delusion of Influence Delusion of Passivity Delusion of Perception

Delusion of Suspicion Thought of Echo Thought of Insertion &

withdrawal


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Sensorium and Cognition

Level of education : finished junior highschool

General knowledge : good

Orientation of time : goodOrientations of place : goodOrientations of people : goodOrientations of situation : goodWorking/short/long memory: goodWriting and reading skills : goodVisuospatial : cant be accessed Abstract thinking : cant be accessed Ability to self care : good


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Self control: enough Patient response to

examiners question:good

Impaired insight Intellectual Insight True Insight

Impulse controlwhen examined Insight


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Physical State

Consciousnes : compos mentisVital sign :

Blood pressure : 130/90 mmHg Pulse rate : 100 x/min Temperature : Afebrile RR : 22 x/min


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Review System

Head : normocephali, mouth deviation (-)

Eyes : anemic conjungtiva (-), icteric sclera (-), pupil isocore

Neck : normal, no rigidity, no palpable lymph nodes

Thorax :

Cor : S 1,2 regular

Lung : vesicular sound, wheezing -/-, ronchi-/-

Abdomen : Pain (-) , normal peristaltic, tympany sound

Extremity : Warm a cral, capp refill


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Mental Status Impairment- Attitude: Cooperative,

hyperactive, bizzare- Mood: Euphoric

- Affect: Appropriate, stabil

- Perception: Gustatory illusion

- Thought Progression: Talkative,

coherrent- Form of Thought: Non-realistic,

fantasy, delusion of suspicionand religion

-Patients response to question:good

- Impaired insight

Didnt take his

medicine Refused going tohospital forroutine control Giving his waresto other peoplewithout anyreason

He didnt work Poor utilization of

leisure time He couldnt

socialize withneighbor

Symptoms

Patient is a male, 43 years old, nicely groomed, has a history of admittion inpsychiatric ward. Symptoms elevation started since 4 days ago.


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Differential Diagnosis

F20.04 Paranoid Schizophrenia incompleteremission

F20.5 Residual Schizophrenia


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Multiaxial Diagnosis

Axis I : F20.00 Continous ParanoidSchizophrenia

Z91.1 Noncompliance of medicationAxis II : Z03.2 noneAxis III : no diagnosisAxis IV : meeting wife and children who didnt

live togetherAxis V : GAF admission 40-31


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RESPONSE PHASE

Target therapy : 50% decrease of symptoms

Emergency department

Haloperidol inj 5mg imDiazepam inj 10mg iv

Maintenance

Risperidone 2x2mg per day

Re-assess patient


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